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Abstract

The aging of the population is a worldwide phenomenon, where 60% of elders live
in developing areas of the world such as Brazil, regions in which few studies
have been carried out.

Objectives

The goal of this study was to evaluate the clinical and demographic profile
of patients with dementing disorders seen at a specialized outpatient clinic
in South Brazil.

Methods

A sample of 105 demented patients seen at the Dementia Outpatient Clinic from
Hospital de Clínicas de Porto Alegre (HCPA), Brazil between June 2004
and June 2008. Evaluation of patients consisted of medical history,
cognitive testing, assessment of functional status (Activities of Daily
Living Scale - ADL; Instrumental Activities Daily Living - IADL) and
application of the Neuropsychiatry Inventory (NPI) for behavioral symptoms.
Severity of dementia was evaluated based on the CDR scale. All patients
underwent laboratory screening tests and brain imaging exams to define
etiology of dementia.

Results

Of the whole sample, 71% were female. Age was 79±8 years
(mean±SD). Educational level was 4±3 years (mean±SD).
Sixty-four patients (60%) presented the diagnosis of Alzheimer’s disease. Of
the whole sample, 26.7% were classified as CDR=1, 44% as CDR=2 and 29. 3% as
CDR=3. A significant difference on the Mini Mental State Examination (MMSE)
and functional status scores was observed among the CDR categories
(severity). No significant association was found between severity and
impairment on memory tests and behavioral symptoms.

Conclusions

Alzheimer’s disease was the most common etiology, followed by vascular
dementia. At diagnosis, most patients presented mild to moderate severity of
dementia, independent of cause.

Conclusões

The aging of the Brazilian population is an ongoing reality, and currently the number of
elderly people in Brazil is estimated at over 20 million.1 Among the major consequences of this growth is an
increase in the prevalence of dementia, particularly Alzheimer's disease.2,3

Presently, dementia is thought to affect 24 million persons worldwide and is expected to
rise to 42 million by 2020. Furthermore, 60% of this demented population lives in
developing areas of the world, a proportion expected to increase to up to 71% by the
year 2040.4

One of the Brazilian studies evaluating elderly people in the community found a
prevalence of dementia of 7.1%.3 The
same investigation also demonstrated that Alzheimer's disease was the most common
etiology, followed by vascular dementia. Likewise, in most studies involving patients
seen at outpatient dementia clinics, Alzheimer's disease was the most common type of
dementia observed .5-7 Only one study showed a predominance of vascular
dementia over Alzheimer's, albeit showing only a small difference between the diseases.
The majority of studies also show a mean educational level of less than 5 years. Not all
studies evaluated the severity of dementia at diagnosis. However, one study reported
that almost 50% of cases were minimal or mild.8

Conditions that cause cognitive impairment, particularly dementias, are under diagnosed
in the primary care setting.9,10 Patients may be not adequately
evaluated, and the diagnosis ends up being delayed. A study which evaluated the rate of
dementia in primary health care, observed that less than a half of the patients with
dementia had their diagnosis documented in a primary medical care setting. This
eventually leads to an increase in diagnoses of these cases in specialized hospital care
settings.11

A few studies in Brazil have reported the different etiologies of dementia3, 5-7,9,10 but none of these were carried out in
the South of the country.

The aim of this study was to evaluate the clinical and demographic profile of patients
with dementing disorders seen at an outpatient clinic in a University Hospital in the
city of Porto Alegre, Rio Grande do Sul State, investigating etiology, severity,
cognitive and functional status, and behavioral symptoms.

Methods

This study sample consisted of 105 demented patients seen at the Dementia Outpatient
Clinic of Hospital de Clínicas de Porto Alegre (HCPA) during the period
spanning from June 2004 to June 2008. The diagnosis of dementia was based on the
Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV)
criteria.12 The diagnosis
of Alzheimer’s disease (possible or probable) was made according to the National
Institute of Neurological and Communicative Disorders and Stroke - Alzheimer Disease
and Related Disorders Association (NINCDS-ADRDA) criteria.13 The diagnosis of vascular dementia followed the
National Institute of Neurological Diseases and Stroke - Association Internationale
pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) criteria of
probable and possible vascular dementia.14 The diagnosis of Frontotemporal dementia was based on the
consensus on clinical diagnostic criteria for Frontotemporal lobar
degeneration.15

Evaluation of patients entailed collection medical history and performing an exam and
cognitive testing, which included the Mini Mental State Examination
(MMSE),16 a word list
(10-item list in a simple immediate recall paradigm - word span - WS)17 and Wechsler's immediate logical
memory test (MLi).18 The
Activities of Daily Living Scale (ADL) and the Instrumental Activities of Daily
Living Scale (IADL)19 were used to
evaluate functional status while the Neuropsychiatry Inventory (NPI) was employed to
assess behavioral symptoms.20 The
cutoff scores to indicate impairment on the word span was 4 17 and for the logical memory test
was 4.18

Patients were classified, according to dementia severity into mild, moderate and
severe, based on the Clinical Dementia Rating Scale (CDR). 21

The study was approved by the Ethics Committee for Research of the Hospital de
Clínicas de Porto Alegre. All subjects and/or their proxies signed an
informed consent term.

Data analysis

The statistical analysis was performed using the Statistical Package for
the Social Sciences (SPSS for Windows 14.0) software. Descriptive
statistics (mean, SD and frequency) were calculated for demographic data,
symptoms of NPI, MMSE and CDR. Parametric data were analyzed by one-way ANOVA
with Tukey’s post-hoc test. The Chi-square test (with Yates correction or Fisher
exact) was used for the association analysis.

Results

The frequency of type of dementia is shown in Table
1. Alzheimer's disease was the most frequent, followed by vascular
dementia.

When comparing patients with Alzheimer's and vascular dementia, these being the most
frequent etiologies, a significant difference among the groups in relation to gender
was detected, whereby the female gender predominated in AD, whereas males
predominated in VD (Table 2).

We also observed performances below the cutoff point in 90.3% of patients on the word
span and in 98.5% on the immediate logical memory test (MLi). There was a
significant difference in the scores for ADL, IADL and MMSE for dementia according
to the CDR scale. Borderline significance (p=0.053) was observed for the WS test
(one-way ANOVA with Tukey's post hoc) (Table 3).

Frequency and severity of behavioral symptoms, as well as distress of the caregiver,
showed no significant differences on the severity of dementia scale (one-way ANOVA
with Tukey post hoc) (Table 3).

Discussion

The present study evaluated the clinical and demographic characteristics of dementia
patients from an outpatient clinic seen during a period of 4 years.

Alzheimer's disease was the most frequent cause, with patients being predominantly at
moderate to severe stages according to CDR, at time of diagnosis. A clear
predominance of females was also observed. These patients showed lower educational
attainment.

After Alzheimer's disease, vascular dementia was the second most frequent cause of
dementia. This finding is similar to results observed in most studies carried out in
Brazil3,5-7 and in
outpatient clinics from tertiary facilities. Only one report showed vascular
dementia and males as the most prevalent aspects of the sample.8

The frequent co-morbidities and the characteristics of the health service - a
reference center for the diagnosis and treatment of dementia - could explain the
high rate of unspecified dementia. Furthermore, the majority of patients were at a
severe stage of the disease on the first evaluation where this fact could have
precluded a better approach and hampered evaluation of important symptoms for
diagnosis.

The mean educational level of the subjects in this sample (4 years) was similar to
the average for the elderly population of Rio Grande do Sul state (4.1 years), but
was lower than that observed in the city of Porto Alegre (7.1 years),1 home to 90% of the study
participants. One explanation for the lower educational level of these patients in
relation to the elderly population of Porto Alegre could be the association with
higher prevalence of dementia observed in previous investigations.22-25

At diagnosis, 71.8% of patients were at a moderate to severe stage of the disease,
reflecting the difficulty in performing early diagnosis in this facility. This may
in part be due to lack of awareness of the population regarding symptoms of dementia
and the general assumptions of memory problems during normal aging. On the other
hand, the use of cognitive screening in the routine evaluation of elderly people
with cognitive problems is not a general rule in the medical practice. Thus,
specialized medical care is only sought when symptoms begin to exert an evident
functional impact and other neuropsychiatric symptoms, when the disease is already
at more advanced stage.6,11

The scores on the MMSE presented a decline across the three categories of severity
(CDR 1, 2 and 3). We recognized congruence between the direction of the decline of
the MMSE scores and worsening severity. However, the average scores on the MMSE in
each category were considered low for the corresponding CDR. Nevertheless, level of
education could be an important factor for this finding. Similarly, worsening on
functional scores (Activities of Daily Living and Instrumentals Activities of Daily
Living) was observed. These functional instruments of assessment are important for
following up dementia patients, as well as measuring deterioration and guiding
appropriate management.

Neuropsychiatric symptoms are commonly found in elderly patients with dementia and
AD. The relationship between the prevalence of neuropsychiatric symptoms and the
severity of dementia has varied widely in several studies, and may not present a
significant difference26 in our
sample. The frequency and severity of behavioral symptoms, as well as family
distress did not increase with severity. Frequency of neuropsychiatric symptoms and
distress was higher among patients at a moderate stage of dementia, independent of
diagnosis.

Studies such as these, as well as epidemiological investigations, are very important
to raise awareness of the proportion of different etiologies of dementia in Brazil,
enabling the development of more specific prevention strategies and early
diagnosis.